SOUTH CENTRAL BEHAVIORAL HEALTH REGION
MENTAL HEALTH DISABILITY SERVICES
Application Form
Application Date: Date Received by local MHDS Office:
Name of agency/contact person completing this form, including contact information:
Prefix: Dr. Miss Mr. Mrs. Ms. Prof.
FirstName: Middle Name: Last Name: Maiden/Nickname:______
Suffix:D.D. Esq. I II III Jr. MD PhD Sr. Start Date: ______End Date: ______
Date of Birth: Sex: Female Male
Race: White Black or African AmericanAmerican Indian or Alaska Native Asian or Pacific Islander
Other (biracial; Sudanese; etc.) ______Unknown
US Citizen:Yes No SSN#:
Marital Status: Single Married(includes common law) Divorced Separated Widowed
Ethnicity:Hispanic or LatinoNon Hispanic or Latino
Primary Language: English Spanish French German Vietnamese Other: ______
Legal Status: Voluntary Involuntary-Civil Involuntary-Criminal Probation Parole Jail/Prison
State ID #: ______Legal Issues:Yes No If yes, please specify: ______
Blind Determination: Yes No Determination Date:______
Home Phone: Work/Other Phone: ______Cell Phone: ______Email: ______
Current Address: Street City State Zip County
Dates of Residency at this address: to
Current Residential Arrangement:(Check applicable arrangement)
Private Residence/Household – Alone Private Residence/Household – With Relatives
Private Residence/Household – With Unrelated Persons Foster Care/Family Life Home
Correctional Facility Substance-Related Treatment Facility 24-Hour Habilitation Home
24-Hour Supported Community Living Home Residential Care Facility(RCF) RCF/ID RCF/PMI
Intermediate Care Facility(ICF)/Nursing Home ICF/ID State MHI State Resource Center
Homeless/Shelter/Street Other: Explain______
Mailing Address: Same Other: ______
StreetCityState Zip County
Veteran Status: Yes No Military Branch and Type of Discharge: ______Dates: ______
Current Employment: (Check applicable employment)
Unemployed, available for work Unemployed, unavailable for work Employed, Full time
Employed, Part timeRetiredStudent
Work ActivitySheltered Work EmploymentSupported Employment
Vocational RehabilitationSeasonally EmployedArmed Forces
Homemaker Other
Current Employer: Position:
Dates of employment: Hourly Wage: Hours worked weekly: ______
Employment History: (list starting with most recent to all previous. Use another sheet if more space is needed)
Employer / City, State / Job Title / Duties / To/From1.
2.
3.
4.
Education: Interested Persons:
Years of Education: ______Name:______Relationship: ______
GED: Yes No Phone: ______
H.S. Diploma: Yes No
College Degree: ______Name:______Relationship: ______
Phone: ______
Guardian/Payee/Conservator: YesNo
Legal Guardian Protective Payee Conservator Legal Guardian Protective Payee Conservator
(Check any that are appointed and write in name etc.) (Check any that are appointed and write in name etc.)
Name: Name:
Address: Address:
Phone: Phone:
Others in Household:
First Name and Last Name / Date of Birth / Relationship1.
2.
3.
4.
Gross Monthly Income (before taxes): Applicant Others in Household
(Check type & fill in amount)Amount: Amount:
Veterans Benefits______
Social Security/SSDI______
SSI______
Employment Wages______
Workers Comp
Public or General Assistance
Private Relief Agency
Food Assistance
Family and Friends
Child Support
FIP
R/R Pension
Other (Unemployment, etc)
Total Monthly Income:
NOTICE: Proof of income may be required with this application including but not limited to pay-stubs, tax-returns, etc.
If you have reported no income above, how do you pay your bills? (Do not leave blank if no income is reported!)
Household Resources: (Check and fill in amount and agency):
Type Amount Bank, Trustee, or Company
Cash on Hand
Checking Account
Savings
Time Certificates
Burial Fund/Plot/Life Ins(cash value)
CDs (cash value)
Stocks/Bonds(cash value)
Dividend Interest(cash value)______
Trust Funds
Retirement Funds(cash value)______
Other______
Total Resources:
Motor Vehicles: Yes No Make, Model & Year: Value:
(include car, truck, motorcycle, etc.) Make, Model & Year: Value:
Do you, your spouse or dependent children own or have interest in the following:
House including the one you live in Any other real-estate or land Other
If yes to any of the above, please explain:
Health Insurance Information: (Check all that apply)
Primary Carrier (pays 1st) Secondary Carrier (pays 2nd)
Applicant Pays Medicaid Applicant Pays Medicaid
Medicare Private Insurance Medicare Private Insurance
No Insurance Marketplace Choice No Insurance MarketplaceChoice
Company Name Company Name
Address Address
Policy Number: Policy Number
(or Medicaid/Title 19 or Medicare Claim Number) (or Medicaid/Title 19 or Medicare Claim Number)
Have you applied for all other public programs? (Please indicate dates applied and decision if applicable):
Social SecuritySSI Medicaid
Veterans Unemployment Food Assistance
FIP Other Other
Disability Group/Primary Diagnosis:
40-Mental Illness42-Intellectual Disability43-Developmental Disability47-Brain Injury35-Substance Abuse
Specific Diagnosis determined by: Date:
Axis I: Dx Code:
Axis II:Dx Code:
Axis III: Dx Code:
Axis IV: Dx Code:
Axis V: (GAF Score & date given):
Do you receive any current mental health or substance abuse services (include provider name, location, & dates):
Do you take any psychotropic medications? Who prescribed them and what was the date?
Why are you here today? What services do you need? (this section must be completed as part of this application):
Service RequestedProvider (if known)Rate/UnitEffective Date
Service RequestedProvider (if known)Rate/UnitEffective Date
Service RequestedProvider (if known)Rate/UnitEffective Date
Service RequestedProvider (if known)Rate/UnitEffective Date
Service RequestedProvider (if known)Rate/UnitEffective Date
Referral Source:
Self Community Corrections Family/Friend(s) Social Service Agency Targeted Case Management
IHH Care CoordinatorHospital Physician RCF/ICF Other
The above listed services have been discussed with me and are requested with my knowledge and consent.
As a signatory of this document, I certify that the above information is true and complete to the best of my
knowledge, and I authorize the County MHDS staff to check for verification of the information provided including,
but not limited to, verification with local and/or state Iowa Dept. of Human Services (DHS) staff. I understand that
the information gathered in this document is for the use of the County in establishing my ability to pay for services
requested, in assuring the appropriateness of services requested, and in confirming residency. I understand that
information in this document will remain confidential.
Applicant’s Signature (or Legal Guardian) Date
______
Signature of other completing form if not Applicant or legal Guardian Date
HIPAA Notice of Privacy Practice Provided: Yes No Signature: ______
NOTE: DO NOT WRITE IN THE SPACE BELOW-FOR MHDS USE ONLY
Unique ID#:______Date Contacted: ______
Disability Group-DX Type: MIID DD BI SA
Residency: ______(Attach Residency Checklist if needed)
Determination: Accepted Denied (see comments below) Pending (see comments below)
Funding Secured: YES NO Arranged: ______
Date of Decision: ______Date NOD sent: ______
If denied, check applicable reason:
Over income/resource guidelinesOther county of residence ______
Does not meet diagnostic criteria Applicant desires to stop process
Does not meet plan criteriaOther______
Assessment does not meet criteria
Other referrals given (DHS, TCM, IHH, etc.): ______
County Co-payment amount/terms (if applicable): ______
MHDS staff making determination & date: ______
Comments: